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Glass Ionomers For

Direct-Placement
Restorations
A Peer-Reviewed Publication
Written by Howard E. Strassler, DMD, FADM, FAGD (Hon)

PennWell designates this activity for 3 Continuing Educational Credits

Publication date: February 2011 Go Green, Go Online to take your course

Expiry date: January 2014
Supplement to DE. This course has been made possible through an unrestricted educational grant. The cost of this CE course is $59.00 for 3 CE credits.
Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.
Educational Objectives
The overall goal of this course is to provide the reader with
information on glass ionomer cement restoratives. Upon
completion of this course, the reader will be able to do the
following:
1. List the two types of chemistries used for the setting
reaction of glass ionomer cements.
2. Describe the mechanism of action for the adhesion of
glass ionomer cements to tooth structure.
3. List and describe the benefits of fluoride provided by
glass ionomer cements.
4. List the restorative clinical indications for a direct-
placement glass ionomer cement.
Abstract
Glass ionomer cements are self-adhesive to enamel and
dentin, provide for caries-protective fluoride release at the
margins of restorations, can be recharged with fluoride and
are moisture tolerant. They are unique restorative materials
that are available in several chemical and physical formula-
tions that in turn determine their clinical uses.
Introduction
Glass ionomer cements (GIC) are unique restorative materi-
als with many uses in clinical practice. What differentiates
GIC from other restoratives is their chemistry, which allows
them to be self-adhesive to enamel and dentin and provide
for caries-protective fluoride release at the margins of res-
torations, as well as their ability to have the fluoride within
their chemical matrix recharged by outside exposure to
other fluoride-containing materials. Other unique features
include their moisture tolerance, allowing GIC to be used
for a wide variety of clinical applications. This article will
provide the clinician with an overview of the advantages of
GIC for direct-placement restorations that are based upon
their chemistry and physical properties. Also, while this
article is focused on direct-placement GIC for restorations,
the different formulations, adhesive properties, differences in
chemistries and viscosities for placement, physical properties,
and appearance provide for a wide range of clinical uses for
GIC that allow them to be used as a liner, base, luting cement,
sealant and surface restorative material.
Chemistry of glass ionomer cements
GIC are classified according to their chemical formula-
tion into two categories: conventional (or traditional) and
resin-modified.1 Conventional glass ionomer cements
undergo a chemical self-setting acid-base reaction created
by mixing an ion-leachable (fluoride ion) fluoroalumino-
silicate glass (powder) with an aqueous polyacrylic acid or
polycarboxylate acid (liquid). This advancement combined
the advantages seen with early silicate cements (chemically
leachable (fluoride ion) fluoroaluminosilicate glass [powder]
and phosphoric acid [liquid]) and the adhesive properties
2 www.ineedce.com
of zinc polycarboxylate cements (zinc-oxide [powder] and
polyacrylic acid [liquid]). This first type of GIC was devel-
oped by Wilson and Kent.2 These changes and developing
a higher-viscosity, thicker mix with the chemistry of con-
ventional GIC resulted in improvements in tensile strength,
compressive strength and fracture toughness; greater wear
resistance and higher fluoride release were also achieved.3
Conventional glass ionomer cements generally have
relatively poor physico-mechanical properties and are
more prone to wear when compared to composite resins,
and they have a very slow self-setting reaction. Preliminary
finishing could not be done for 10 minutes and final finish-
ing had to wait for at least 24 hours.3,4 Conventional GIC
used as tooth-colored restorative materials also have poorer
esthetics compared to composite resin. In order to expand
the clinical uses of GIC, resin was added to the formula-
tion. This resin-modified glass ionomer cement (RMGI)
chemistry was enhanced with the addition of water-soluble
photopolymerizable resin monomers, 2-hydroxyethyl-
methacrylate (HEMA) to the acidic cement liquid, and
for powder-liquid RMGI some manufacturers use propri-
etary resin formulations.1,5,6,7 The change in formulation
of RMGI allowed them to be dual-cured: self-setting and
light-cured. When compared to conventional GIC, resin-
modified glass ionomers provide for improved physico-
mechanical properties, resistance to early contamination
by moisture, less microleakage, and improved adhesion to
enamel and dentin combined with significant improvement
in esthetic properties.1,6,8,9,10,11 One recent modified formu-
lation includes more resin as well as nanoparticles (Ketac
Nano, 3M ESPE). In an effort to improve physical proper-
ties for GIC as a posterior restorative, manufacturers also
developed metal-reinforced glass ionomers by adding silver
amalgam alloy powder to GIC (Ketac Silver, 3M ESPE;
Miracle Mix, GC America).
Table 1. Comparison of selected physical properties of resin-modi-
fied glass ionomers (RMGI), conventional glass ionomers (GIC) and
hybrid composite resins (CR)
Property RMGI GIC CR
Compressive Med Low-Med Med-High
strength
Flexural strength Med Low-Med Med-High
Flexural modulus Med Med-High High
Wear resistance Med Low High
Fluoride release Med-High Med None
Fluoride recharge Med-High High None
Setting shrinkage Low-Med Low Med
Esthetics Good Acceptable Excellent
Adapted from: Powers J. Preventive materials. Resin Composite Re-
storative Materials. In Craig’s Restorative Dental Materials. Powers
JM, Sakaguchi RL. Mosby Elsevier. 2006; pp. 161-188; pp.189-212.
 Clinical recommendations for these products are for use
as long-term temporary restorations for caries control, to
seal access openings of endodontically treated teeth, for core
build-ups where at least 50% of the tooth structure was re-
maining, and for restoring primary teeth. These materials are
not recommended as definitive restorations for the permanent
dentition in stress-bearing areas because they do not have the
wear resistance and resistance to chemical erosion of amalgam
or composite resin.
Contact with water during the initial placement and early
setting of conventional glass ionomers can cause inhibition
and delay in the setting reaction. It is critical to the clinical
procedure that at the time of placement of the glass ionomer
the dentin at the dentin-restorative interface be moist, and
not desiccated, to ensure good adhesion. RMGI have re-
duced moisture sensitivity and are more moisture tolerant.1
For powder-liquid RMGI, the proportion of self-setting
acid-base reaction in RMGI is a minor part of the setting
reaction. This change in reaction kinetics contributes to a
dual-cured (self-setting and light-cured) reaction that pro-
vides RMGI with rapid setting and greater color stability.1
In deeper restorations where the light intensity is compro-
mised, the continued polymerization by self-setting of the
resin-modified glass ionomer occurs over time.12 For most
resin-modified glass ionomers, it is recommended that the
material be placed in increments no greater than 2 mm and
each increment be light-cured. Paste-paste RMGI formula-
tions are available where use of a product-specific cavity
cleanser/primer is required before placement of the restor-
ative material. The cavity cleansers/primers for RMGI are
similar to those used for conventional GIC: i.e., a polyacrylic
cavity cleanser is used to remove the smear layer.
Recently, a zinc-reinforced glass ionomer (Chemfil
Rock, Dentsply) has been introduced that is formulated
with a zinc-containing glass that provides reinforcement.
This new zinc-reinforced glass ionomer is different from
past resin -modified and conventional glass ionomer chem-
istries. It offers improved fluoride release, combined with a
novel acrylic acid copolymer that improves wear resistance,
flexural strength and fracture toughness. The high-viscosity,
non-sticky formulation is mixed with a mechanical mixer in
a syringeable capsule, which makes it easier to manipulate
and pack, and features faster setting with improved physical
properties for use in posterior teeth. It is also more moisture
tolerant than conventional glass ionomers and has a radi-
opacity consistent with good readability in radiographs. Un-
like earlier-generation resin-modified and conventional glass
ionomer cements, the novel chemistry eliminates the need
for two steps that have been required in the past – pretreat-
ment with a cavity cleanser and surface coating of the glass
ionomer after placement. Its physical property enhance-
ments allow for greater durability when placing the material
in posterior teeth and for pediatric applications in deciduous
posterior teeth.13
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Mechanism of adhesion of glass ionomer
restoratives
Both GI and RMGI are self-adhesive to enamel and dentin.
The mechanism of adhesion is an ionic bond between the
glass ionomer and the calcium within the tooth structure.1,4,5
(Figure 1) The adhesion of RMGI is slightly different; it
forms a modified hybrid zone with the tooth structure.3,4
When using RMGI to increase the bond to enamel, it is
recommended that the enamel be beveled and a weak or-
ganic acid, the cavity cleanser/conditioner that is provided
with the material, be used. Recent evidence for RMGI
demonstrates that even though phosphoric acid etching is
not recommended by manufacturers because it dissolves and
removes the calcium, resulting in weaker and compromised
adhesion, the resin/etched dentin/enamel interface will
still demonstrate adhesion.14,15 The use of cavity cleansers
(polyacrylic acid) gently dissolves and removes the dentin
and enamel smear layers without removing the calcium in the
tooth that is important for the self-adhesion of glass ionomers
(in contrast to etching, which results in removal of tooth
structure for micromechanical retention of composites).
Figure 1. Mechanisms of adhesion for glass ionomers
Source: Adapted from Burgess JO. Compend Contin Educ Dent.
2008; 29:82-94.
The bond to dentin with glass ionomers is predictable. In
clinical studies, retention of RMGI used to restore non-
carious cervical notched lesions (NCCL) was greater than
90% at three years.16 Retention of conventional GIC at ten
years has been reported at 83% for similar restored lesions.17
When shear bond strength to dentin has been evaluated it
has been noted that when stressed there is a cohesive fracture
of the glass ionomer, leaving the glass ionomer still bonded
to the dentin.18,19 Recent research with the new generation
zinc-reinforced glass ionomer demonstrates adhesive inter-
faces similar to that seen with resin-modified glass ionomer.
When restoring Class V non-carious cervical lesions
with RMGI, it was found that the dentin should be lightly
roughened and prepared with a rotary instrument to create
a uniform dentin smear layer and clean dentin surface. It is
also important to use a cervical matrix to provide for 100%
leak-free restorations.12 Clinically the cervical matrix allows
the material to be adapted to the margins of the preparation
under pressure as compared to adapting the restorative with
a hand instrument, which can have the tendency to pull the
restorative away from the margin. Another study investi-
gated marginal adaptation of RMGI and recommended that
restorations be finished in a separate appointment to allow
for water sorption to improve marginal adaptation.20 When-
ever placing Class V restorations, potential contamination
with sulcular fluid or moisture is a risk factor. It has been
reported that when bonding RMGI to slightly moist dentin
the restorative material exhibits moisture tolerance with no
reduction in shear bond strength.21
Fluoride release of glass ionomer restoratives
A critical property for GIC that makes them unique and de-
sirable is their ability to release fluoride from the glass fillers
to adjacent tooth surfaces. Water, one of the constituents of
GIC, is part of the acid-base reaction for setting; the water
also plays a critical role in the fluoride release of GIC.21 The
aqueous phases of the set GIC exist in the form of hydrogels
that allow a chemical equilibrium with an ion movement
between the GIC and the environment – the oral cavity and
the surrounding tooth structures.22,23 It has been shown
that fluoride-releasing materials are effective in inhibiting
demineralization while providing for the remineralization
of adjacent tooth structure.24,25 This has important impli-
cations for GIC as restorative and preventive materials.
When resin-modified glass ionomer cement was compared
to amalgam for Class II restorations in primary molars,
the RMGI exhibited less recurrent caries at the margins.26
These primary molars had been restored with amalgam or
RMGI three years earlier and were then collected for evalu-
ation when exfoliated. The teeth were sectioned and the de-
mineralization at the margins was evaluated using polarized
light microscopy. It was found that the gingival margin of
the amalgam restorations demonstrated demineralization of
2.16 × 102 ± 5.48 × 102 when compared to RMGI restora-
tions with demineralization of 4.87 × 104 ± 2.65 × 104. The
RMGI had significantly less adjacent demineralization than
the amalgam (P<.0001).26 Other studies have investigated
the potential for RMGI to inhibit enamel demineralization
on interproximal surfaces.27,28,29 These findings suggest that
RMGI enhance the prevention of enamel demineralization
not only on the restored teeth but on the adjacent teeth as
well. The mechanism of prevention may be twofold: rem-
ineralization of the adjacent tooth structures to the GIC
restoration due to the fluoride, and the cariostatic properties
of GIC that may affect bacterial metabolism.30 These find-
ings have important implications for patients with caries
risk factors.4
How effective is the fluoride release over time? GIC
have been described as a “smart” restorative material be-
cause the fluoride they contain is not only released to sur-
4 www.ineedce.com
rounding tooth structure but can also be recharged in the
glass ionomer.31,32,33,34 This is referred to as the “reservoir
effect” and is an important feature of GIC.5 GIC release
fluoride from the unreacted glass fillers over time into the
saliva. From the saliva there is an ion exchange that occurs,
with the fluoride ions diffusing from the GIC (area of high
concentration) to the tooth (lower fluoride concentration).
Over time there is an equilibrium as the fluoride is incor-
porated into the hydroxyapatite crystals of the enamel and
dentin, over an area of approximately 1-3 mm surrounding
the restoration, forming hydroxyfluorapatite. Recharging
of the GIC with fluoride in the unreacted glass ionomer
filler can be accomplished with fluoride-containing oral
care products, including topical fluoride gel applications,
fluoride-containing toothpastes and mouth rinses.4,35,36,37
This recharging effect allows GIC to retain their caries
protective abilities.
Glass ionomer restoratives for direct place-
ment restorations
Glass ionomer cements have many clinical uses. (Table 2)
In recent years there have been significant improvements to
glass ionomer cements that allow them to be used for routine
restorations and provisional restorations. Glass ionomer ce-
ments can be used to successfully restore both permanent
and primary teeth based upon these clinical implications.
Table 2. Clinical applications for direct-placement glass ionomer
restoratives
Class V restorations
Caries control as provisional restorations
Blockout of undercuts in crown and onlay preparations
Dentin substitute as a base material
Small core/foundation build-ups where at least 50% of the
tooth structure is remaining
Posterior restorations in primary teeth
Temporary restoration of endodontic access preparations
Temporary restorations anterior/posterior teeth
Non-stress-bearing restorations
Repair adjacent to crown margins due to subgingival caries
Repair of endodontic root perforations
Repair of external root resorptive lesions
Class V restorations
When there is excellent access to the gingival margins,
RMGI can be used effectively for moderately deep and deep
Class V NCCL in need of restoration; shallow, moderate
and deep Class V NCCL with dentin hypersensitivity; and
Class V carious lesions. For the patient with moderate-sized
notch-shaped lesions on the cervical surfaces of anterior and
posterior teeth that exhibit dentin hypersensitivity, RMGI
are indicated because of their more esthetic appearance
when compared to conventional GIC and because place-
ment of Class V etch-and-rinse adhesive composite resin
restorations can be problematic to highly sensitive root sur-
faces.38,39 Use of glass ionomers also eliminates the multiple
steps for placement required with composite resin.40 When
using RMGI to restore NCCL lesions it is recommended
that the dentin and enamel surfaces be cleaned with a
pumice-water paste and that the enamel be beveled before
restoration. For patients at high caries risk presenting with
multiple Class V carious lesions, RMGI with fluoride
release offer an advantage over composite resin. In recent
years we have seen an increase in cervical caries and root
sensitivity. Gingival recession of 3 mm or more has been
reported to be present in at least 22% of the adult popula-
tion in one or more teeth,41 placing these patients at risk for
dentin hypersensitivity of the exposed root surfaces as well
as root caries.42 Additionally, the baby boomers have a 30%
likelihood of having recession on one or more teeth. Also,
patients that have had or are having periodontal therapy are
at risk of dentin hypersensitivity at rates of 55% after peri-
odontal therapy (scaling and root planing and periodontal
surgery).42 According to recent reports of adults over the age
of 60, almost 32% had root caries or a restored root surface.
There are also many medications that contribute to xerosto-
mia, which also increases caries risk in general.43,44
The earliest forms of RMGI were powder-liquid for-
mulations; they had a low viscosity and could be difficult
to place and adapt in the cavity preparation with a hand
instrument. Dispensing of RMGI for restorations has im-
proved with the use of predose capsules that are activated
and mixed using mechanical mixers. Cervical matrices with
a variety of shapes and sizes for anterior teeth, premolars
and molars provide for ease of placement for resin-modified
glass ionomers, as well as for better marginal adaptation
than using hand instruments.45 These cervical matrices can
also be used for composite resins. (Figure 2)
Figure 2a. Cervical matrices Figure 2b. Application of cervical matrix
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Recently, paste-paste RMGI have been introduced
that are easier to mix and place without any change in the
physical properties. From this author’s experience the latest
generation of paste-paste RMGI are also more translucent
appearing than past RMGI. These paste-paste RMGI are
dispensed from double-barreled syringes onto a mixing pad
and require conventional mixing of the pastes on the mixing
pad using a cement spatula. This author would then load
the RMGI into dispensing tubes and apply the RMGI into
the cavity preparation. A recent innovation was the devel-
opment of an automixing predose capsule for placement of
the paste-paste nanoparticle resin-modified glass ionomer
formulation. This automix-quick mix capsule offers the
benefits of significantly fewer air bubbles and voids in the
restoration and improved wear resistance, and the nano-
technology provides for better polishability compared to
other resin-modified glass ionomers on the market.
Case report: Class V restoration
A 29-year-old male patient with multiple Class V carious le-
sions (Figure 3) and high caries risk was treatment planned
for restoration of these lesions with self-mixing nanoparticle
RMGI (Ketac Nano Quick). The teeth were anesthetized
with local anesthesia. For this patient, the use of a dental
dam was not possible because of the multiple preparations
and limited access to the preparations that gingival retrac-
tion retainers would allow. The teeth were prepared using
a #35 inverted cone bur. (Figure 4) The use of inverted
cone burs is preferred because of their shorter length when
compared to 330 burs to reduce the risk of the gingiva being
lacerated during use of the bur in Class V preparations at or
beneath the free margin of the gingiva.
After completion of the cavity preparations, the corre-
sponding one-part light-cure cavity primer was applied to
the cavity preparations (Figure 5), air dried and light-cured
for 10 seconds using a high-intensity LED curing light. The
function of the primer is to wet the surfaces of the cavity
preparation to facilitate adhesion of the restorative material.
The restorative material was applied into the preparations
with an automixing capsule (Figure 6). A cervical matrix
that flexes to fit the contour of the tooth and minimizes
excess of restorative materials for easier finishing was used
to adapt and shape the restoration before light curing. The
restoration was light-cured for 20 seconds with the high-
intensity LED light curing unit. The restorations were then
ready for finishing and polishing. (Figure 7)
Figure 3. Patient with multiple Class V carious lesions
Figure 4. Cavity preparations
Figure 5. Application of light-cured primer
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Figure 6. Self-mixing capsule
Figure 7. Finished restorations
Class V carious lesions
There has been a rise in the presence of “meth mouth” ram-
pant caries, cases where isolation and control of the soft tis-
sue can be very difficult.46 (Figure 8) Also, for many patients,
access with a curing light to the distal and lingual surfaces of
posterior teeth is not possible due to tooth position and an-
gulation of the curing light tip. For patients with recurrent
caries at the margins of existing crowns and bridges where
replacement of the restoration is not feasible, salvaging these
restorations by restoring and repairing the margins with
GIC is a viable choice. For cases where the margins of the
restoration will be subgingival due to caries, access to root
surfaces is difficult and consideration should be given to
new-generation high-viscosity conventional glass ionomer
cements. These glass ionomers are more moisture tolerant
and will set and bond in a compromised field.47
Figure 8. Meth mouth
Caries control and provisional restorations glass ionomer paste was syringed and adapted in the cavity
With the acceptance of total resin adhesion for most restorative preparations. (Figure 12) The GIC was allowed to set undis-
procedures, there has been a desire to eliminate eugenol-con- turbed. This new zinc-reinforced glass ionomer does not re-
taining restoratives in the management of dental emergencies quire a special surface coating during the setting reaction. Six
for deep and large carious lesions in vital teeth requiring in- minutes after activation and mixing, the glass ionomer was
termediate, provisional restorations to maintain pulp vitality. finished with finishing diamonds (Figure 13) and stones using
This treatment of deep caries in vital teeth without pulpal a slow-speed handpiece. Finishing was completed using an
invasion has been referred to as caries control. Caries control is aluminum oxide finishing point in a slow-speed handpiece.
also indicated for single-visit treatment of multiple teeth with (Figure 14)
extensive caries to stabilize the active disease or as a diagnostic
tool to evaluate pulpal response and symptoms after treatment. Figure 9. Root caries on the mandibular second molar
Reinforced zinc oxide and eugenol (ZOE) temporary restora-
tions were for many years the material of choice for these deep
carious lesions because the eugenol has a sedative effective on
the pulp. Unfortunately, these temporary restorations, due to
the presence of residual eugenol-infiltrated dentin after the
removal of the ZOE restorations, have been shown to be detri-
mental to the setting reactions of composite resin restorations
because they inhibit polymerization.48 Dentin containing
residual eugenol can have a negative impact on the resin adhe-
sion of definitive restorations. Since ZOE restoratives also do
not bond to tooth structure they require retentive undercuts
which requires additional tooth removal. An alternative to
the use of ZOE temporary restoratives for caries control is the
new-generation zinc-reinforced self-adhesive one-step GIC.
Conventional GIC have also become popular for the tem- Figure 10. Preparation of carious lesions
porary restoration of endodontic access preparations during
endodontic treatment because they are self-adhesive and will
not contaminate the enamel or dentin, thus allowing for later
use of a composite resin.

Case report: salvaging teeth with multiple

carious lesions
A 79-year-old male patient presented with numerous teeth
with root caries that were subgingival. (Figure 9) He was at
high caries risk due to medication-induced xerostomia and
had inadequate oral hygiene. For many of the teeth, pulp
testing indicated pulp vitality but there was concern that the
size and depth of the preparations might lead to the need for
endodontic treatment. The patient did not want endodontic
treatment. Control of the operatory field was difficult and Figure 11. Capsule activation
some of the preparations were going to be subgingival. It was
decided to place long-term provisional restorations with zinc-
reinforced glass ionomer cement (Chemfil Rock). The carious
mandibular second molar was prepared with a #35 inverted
cone bur. (Figure 10) No pretreatment is required for this
glass ionomer. The capsule was activated by pushing the
plunger against a tabletop until the plunger overlap was less
than 2 mm. (Figure 11) The capsule was then mixed for 15
seconds using a microprocessor-controlled restorative mixer
that provides for consistent mixing. The working time for
zinc-reinforced glass ionomer is 90 seconds. The capsule was
loaded into the extruder and the trigger activated until the
glass ionomer paste was extruded from the capsule tip. The

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Figure 12. Syringing the restorative into the Class V cavity
preparations
Figure 13. Finishing the gross excess with a flame-shaped 50
micron fine finishing diamond
Figure 14. Completed long term glass-ionomer provisional
restorations
8 www.ineedce.com
Case report: caries control
As stated earlier, GIC can be used for the management of
dental emergencies in vital teeth with deep and large cari-
ous lesions requiring intermediate, provisional restorations
that are placed to evaluate and maintain pulp vitality and
for caries control. The vitality of the tooth should first be
determined by pulp testing, radiographic evidence and
patient history (presence and type of symptoms). For the
patient in this case, the symptoms of short-duration pain
on the carious mandibular first molar were consistent
with reversible pulpitis. (Figure 15) The decision was to
perform caries control and reevaluate the tooth in four to
six weeks. Local anesthesia was administered and a dental
dam placed. The caries was removed using a dentin-safe,
caries-removing polymer bur to avoid the potential for a
mechanical pulpal exposure.49 There was no evidence of
caries exposure. (Figure 16) The preparation was restored
with zinc-reinforced GIC (Figure 17) and polished with a
finishing abrasive point. (Figure 18) The completed res-
toration provides for a well-sealed provisional restoration.
(Figure 19)
Figure 15a. Radiographic view of deep carious lesion, mandibular
first molar
Figure 15b. Clinical view of deep carious lesion, mandibular first
molar
Figure 16. Preparation with complete caries removal Figure 19. Completed caries control restoration

Figure 17a. Placement of restorative material with syringe capsule
Pediatric posterior restorations
Glass ionomer cements are excellent restorative materials for
deciduous (primary) posterior teeth.50,51 Since primary teeth
will be exfoliated to allow for eruption of the permanent suc-
cessors, the restoration does not have to be as wear resistant
as with permanent teeth. Also, primary enamel is less wear
resistant than permanent enamel, amalgam and composite
resin.52,53 The recently introduced zinc-reinforced glass
ionomer demonstrates properties desirable for primary tooth
posterior restorations. (Figure 20)

Figure 20. Graphs showing comparative physical properties

Biaxial Flexural Strength after 24 hours
Figure 17b. Adaptation of restorative material to preparation 70
Biaxial flexural strength (Mpa)

margins 60
50
40
30
20
10
0
CF Rock Brand A Brand B

Three-body wear in contact mode

250
Maximum depth (micrometers)

200

150

100
Figure 18. Finishing the restoration
50

0
CF Rock Brand A Brand B
Latta M, Creighton University (2009)

Fracture toughness over time

0.7
Fracture toughness (MPa M)

0.6 CF Rock
Brand A
0.5
Brand B
0.4
0.3
0.2
0.1
0
3h 24h 7d 21d
Lohbauer U, University Medical Center of Erlangen (2009)

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 When treating children, fewer clinical treatment steps because it can be used in a moist field.62 The glass ionomer
will provide for improved results. A significant benefit of pit and fissure sealant allows for fluoride release to the sur-
this zinc-reinforced glass ionomer is that there is no need for rounding tooth structure and also has a semipermeable
pretreatment cavity cleanser or for a coating to be placed over surface to allow the calcium and phosphate ions that are
the restorative material until it reaches full setting in 5-10 present in saliva to pass through the sealant and combine
minutes. It is a single-step, self-adhesive restorative material. with the fluoride to produce remineralization of the enamel
as a fluorapatite. Another unique characteristic of a glass
Glass ionomer sealants ionomer is that it provides for a high burst of fluoride for
Resin-based sealants are highly effective at preventing remineralization combined with a prolonged fluoride release
pit and fissure caries on posterior teeth.54 A review of the over time. If the patient is following the recommendation to
evidence in ten studies of sealants preventing pit and fissure use a fluoride toothpaste, then the patient is recharging the
caries demonstrated that sealants reduced dental caries by glass ionomer with new fluoride ions every day. Following
78% at one year and 59% at four or more years of recall.55 good clinical techniques will assure clinical success with
For at-risk patients, once the posterior tooth has erupted in glass ionomer as a sealant. (Figure 22)
the mouth, it is recommended that the occlusal surfaces be
sealed within 6 months to 1 year. 54,55 Dennison and cowork- Figure 21. View of mandibular second molar with soft tissue over
ers investigated retention of sealants on at-risk teeth that the distal surface
were fully erupted against those that were partially erupt-
ed.56 Three years after resin sealant placement, it was found
that fully erupted, sealed teeth required 0% replacements,
while teeth that had had gingival tissue at the level of the
distal marginal ridge at the time of sealant placement had a
26% sealant replacement rate. When the gingival tissue was
over the distal marginal ridge at the time of placement, the
replacement rate was 54%. Clearly, isolation of field and ac-
cess contribute to resin sealant success.
Here lies the dilemma – clinicians want to seal pits and
fissures when permanent teeth are first erupting, when
isolation is very difficult or impossible. (Figure 21) Resin
adhesion to etched enamel requires a clear, dry enamel
surface. Recent research has investigated the use of glass
ionomer cements for sealant placement because they offer
an advantage over resin sealants for semi-erupted teeth in Figure 22. Glass ionomer sealant after placement
that they are moisture tolerant and adhere to the enamel
surface through ionic bonding (and not through microme-
chanical retention following acid etching).57,58,59,60,61 These
clinical trials have found that the use of glass ionomer
sealants on newly erupted first molars was successful. In
one evaluation of sealants, it was found that unsealed first
molars had a 2.1 times higher chance of developing dentinal
lesions after 5 years than first molars that were sealed using
a GIC sealant when they were newly erupted.58 These stud-
ies demonstrated that GIC sealant retention is significantly
lower after 1 year than resin-based sealants.57-61 This author
would recommend that once the tooth is fully erupted, the
glass ionomer sealant can be replaced when it needs to be
with a resin sealant. This is consistent with the concept that
all sealants need to be reevaluated and maintained. If there Image courtesy of Dr. Mark Grebosky
is partial or complete loss of sealant, the clinician needs to
reapply the sealant. Conclusion
Using glass ionomer pit and fissure sealant (Fuji Triage, While not as esthetic as composite resins, there are specific
GC America) offers significant benefits when sealing an clinical situations where glass ionomers are the materials of
erupting posterior tooth. This has been shown to be able to choice for restoring teeth. In recent years glass ionomer ce-
be used predictably on newly erupted or semi-erupted teeth ments as direct restorative materials have become more user

10 www.ineedce.com
friendly with improved physical properties. Glass ionomer
cements that are designed for posterior use include RMGI,
conventional glass ionomer cements, zinc-reinforced glass
ionomer cement and specialized glass ionomers for sealants.
Glass ionomer cements can also play an important role in
restoration to control rampant caries.
The unique chemistry of a glass ionomer that allows the
release of fluoride and recharge with fluoride has important
clinical implications for patients at risk for caries and with
carious lesions.
References
1 Saito S, Tosake S, Hirota K. Characteristics of glass-ionomer
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2 Wilson AD, Kent BE. A new translucent cement for
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3 Burgess JO. Fluoride-releasing materials and their adhesive
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4 Coutinho E, Yoshyida Y, Inoue S, et al. Gel phase formation
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5 Albers HF. Fluoride-containing restoratives. Adept Report.
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7 Croll TP. Berg JH. Glass-ionomer cement systems. Inside
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8 Uno S, Finger WJ, Fritz U. Long-term mechanical
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9 Mitra SB. Adhesion to dentin and physical properties of
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10 Leinfelder KF. Glass ionomers: current clinical
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11 Hallett KB, Garcia-Godoy F. Microleakage of resin-
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12 Swift EJ Jr, Pawlus MA, Vargas MA, et al. Depth of cure of
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13 Hickel R. Two-year clinical trial ChemFil Rock restoring
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14 Hajizadeh H, Ghavamnasiri M, Namazikhah MS, Majidinia
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16 Gallo JR, Burgess JO, Ripps AH, et al. Three-year clinical
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17 Matis BA, Cochran M, Carlson R. Longevity of glass-
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18 Garcia-Godoy F, Rodriguez M, Barberia E. Dentin bond
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19 Pereira LC, Nunes MC, Dibb RG, et al. Mechanical
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20 Fritz UB, Finger WJ, Shigeru U. Marginal adaptation of
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21 Wilder AD, May K Jr, Swift EJ Jr, et al. Effects of viscosity
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22 McLean JW. The clinical use of glass-ionomer cements.
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23 Hatton PV, Brook IV. Characteristics of the ultrastructure
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24 Francci C, Deaton TG, Arnold RR, Swift EJ Jr, et al.
Fluoride release from restorative materials and its effect on
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25 Donly KJ. Enamel and dentin demineralization inhibition
of fluoride-releasing materials. Am J Dent. 1994; 7:275-278.
26 Donly KJ, Segura A, Kanellis M, Erickson RL. Clinical
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27 Donly KJ, Segura A, Wefel JS, et al. Evaluating the effects of
fluoride-releasing dental materials on adjacent interproximal
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28 Qvist V, Poulsen A, Teglers PT, Mjor IA. Fluorides leaching
from restorative materials and the effect on adjacent teeth.
Int Dent J. 2010; 60:156-160.
29 Mickenautsch S, Yengopal V, Leal SC, et al. Absence of carious
lesions at margins of glass-ionomer and amalgam restorations:
a meta-analysis. Eur J Paediatr Dent. 2009; 10:41-46.
30 Wiegand A, Buchalla W, Attin T. Review of fluoride-
releasing restorative materials – fluoride release and uptake
characteristics, antibacterial activity and influence on caries
formation. Dent Mater. 2007; 23:343-362.
31 Nagamine M, Itota T, Torii Y, et al. Effect of resin-modified
glass ionomer cements on secondary caries. Am J Dent.
1997; 10:173-178.
32 De Moor RJG, Verbeeck RMH, De Maeyer EAP. Fluoride
release profiles of restorative glass ionomer formulations.
Dent Mater. 1996; 12:88-95.
33 Ewoldsen N, Herwig L. Decay-inhibiting restorative
materials: past and present. Compend Contin Dent Educ.
1998; 19:981-988.
34 Vermeersch G, Leloup G, Vreven J. Fluoride release from
glass-ionomer cements, compomers, and resin composites.
J Oral Rehabil. 2001; 28:26-32.
35 Damen JJ, Buijs MJ, ten Cate JM. Uptake and release of
fluoride by saliva-coated glass ionomer cement. Caries Res.
1996; 30:454-457.
36 Diaz-Arnold AM, Holmes DC, Wistrom DW, et al. Short-
term fluoride release/uptake of glass ionomer restoratives.
Dent Mater. 1995; 11:96-101.
37 Hatibovic-Kofman S, Koch G, Elkstrand J. Glass ionomer
materials as rechargeable F-release system. J Dent Res
(Special Issue). 1994; Abstract no. 260.
38 Christensen GJ. Preventing postoperative tooth sensitivity
in Class I, II, and V restorations. J Am Dent Assoc. 2002;
133:229-231.
39 Strassler HE, Serio F. Managing dentin hypersensitivity.
Inside Dent. 2008; 4(7):66-70.
40 Gladys S, Van Meerbeek B, Lambrechts P, et al. Evaluation
of esthetic parameters of resin-modified glass ionomer
materials and a polyacid-modified resin composite in Class
V cervical lesions. Quintessence Int. 1999; 30:607-614.
41 Holland GR, Narhi MN, Addy M, Gangarosa L,
Orchardson R, et al. Gingival recession, gingival bleeding
and dental calculus in adults 30 years of age and older in the
United States, 1988-1994. J Periodontol. 1999; 70:30-43.
42 Tugnait, Clerehugh V. Gingival recession – its significance
and management. J Dent. 2001; 29:381-94.
43 Peker I, Alkurt MT, Usalan G. Clinical evaluation of
medications on oral and dental health. Int Dent J. 2008;
58:218-222.
44 Rindal DB, Rush WA, Peters D, Maupome G.
Antidepressant xerogenic medications and restoration
rates. Community Dent Oral Epidemiol. 2005; 33:74-80.
45 Koprulu H, Gurgan S, Onen A. Marginal seal of a resin-
modified glass-ionomer restorative material: an investigation
of placement techniques. Quintessence Int. 1995; 26:729-
732.
46 Goodchild JH, Donaldson M. Methamphetamine abuse
and dentistry: a review of the literature and presentation of a
clinical case. Quintessence Int. 2007; 38:583-90.
47 Wang XY, Yap AU, Ngo HC. Effect of early water exposure
on the strength of glass ionomer restoratives. Oper Dent.
2006; 31:584-589.
48 Erdemir A, Eldeniz AU, Belli S. Effect of temporary filling
materials on repair bond strengths of composite resins. J
Biomed Mater Res B Appl Biomater. 2008; 86B(2):303-309.
49 Strassler HE. Evaluation of caries removal burs on sound
healthy dentin. J Dent Res (Special Issue IADR abstracts).
2011; 90:abstract no. 145002.
50 Qvist V, Laurberg L, Poulsen A, et al. Eight-year study on
conventional glass ionomer and amalgam restorations in
primary teeth. Acta Odont Scand. 2004; 62:37-45.
51 Qvist V, Manscher E, Teglers PT. Resin-modified and
conventional glass ionomer restorations in primary teeth:
8-year results. J Dent. 2004; 32:285-94.
52 Correr GM, Alonso RC, Consani S, et al. In vitro wear of
primary and permanent enamel. Simultaneous erosion and
abrasion. Am J Dent. 2007; 20:394-399.
53 Qvist V, Poulsen A, Teglers PT, et al. The longevity of
different restorations in primary teeth. Int J Paediatr Dent.
2010; 20:1-7.
54 Gooch BF, Griffin SO, Gray SK, et al. Preventing dental
caries through school-based sealant programs: updated
recommendations and reviews of evidence. J Amer Dent
Assoc. 2009; 140:1356-1365.
55 Llodra JC, Bravo M, Delgado-Rodriguez M, Baca P, Galvez
R. Factors influencing the effectiveness of sealants: a meta-
analysis. Community Dent Oral Epidemiol. 1993; 21:261-
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12 www.ineedce.com
56 Dennison JB, Straffon LH, More FG. Evaluating tooth
eruption on sealant efficiency. J Am Dent Assoc. 121:610,
1990.
57 Taifour D, Frencken JE, Van’t Hof MA, Beiruti N, Truin
GJ. Effects of glass-ionomer sealants in newly erupted first
molars at 5 years: a pilot study. Community Dent Oral
Epidemiol 31:314-319, 2003.
58 Pardi V, Pereira AC, Mialhe FL, Meneghim MDe C,
Ambrosano GM. A 5-year evaluation of two glass-ionomer
cements used as fissure sealants. Community Dent Oral
Epidemiol 31:386-391, 2003.
59 Kervanto-Seppala S, Lavonius E, Pietila I., et al. Comparing
the caries preventive effect of two fissure sealing modalities
in public health care: a single application glass ionomer and
a routine resin-based sealant programme. A randomized
split-mouth clinical trial. Int J Paediatr Dent. 2008; 18:56-61.
60 Yengopal V, Mickenautsch S, Bezerra AC, Leal SC. Caries-
preventive effect of glass ionomer and resin-based fissure
sealants on permanent teeth: a meta analysis. J Oral Sci.
2009; 51:373-382.
61 Niedeman R. Glass ionomer and resin-based fissure
sealants- equally effective? Evid Based Dent. 2010; 11:10.
62 Strassler HE, Grebosky M. A moisture tolerant glass
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Restor Pract. 2005; 9(6):59-60.
Author Profile
Dr. Howard Strassler is professor and director of operative
dentistry at the University of Maryland Dental School in the
Departments of Endodontics, Prosthodontics, and Operative
Dentistry. He is a fellow in the Academy of Dental Materi-
als and the Academy of General Dentistry, a member of the
American Dental Association, the Academy of Operative
Dentistry, and the International Association for Dental
Research. Dr. Strassler has published more than 400 articles
in the field of restorative dentistry and innovations in dental
practice, coauthored seven chapters in texts, and lectured na-
tionally and internationally. Dr. Strassler has a general prac-
tice in Baltimore, Maryland, limited to restorative dentistry
and aesthetics.
Acknowledgment
The author would like to thank Neal Patel and Tuan Nhu,
dental students at the University of Maryland Dental School,
for their assistance with this article.
Disclaimer
The author(s) of this course has/have no commercial ties with
the sponsors or the providers of the unrestricted educational
grant for this course.
Reader Feedback
We encourage your comments on this or any PennWell course.
For your convenience, an online feedback form is available at
www.ineedce.com.
Online Completion
Use this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the
online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your
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and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

Questions

1. The chemistry of a GIC allows it to a. always lower than with a composite resin 18. Pretreatment with _____ is necessary for
_____. b. always negligible compared to with a conventional zinc-reinforced glass ionomer cement.
a. be self-adhesive to enamel and dentin glass ionomer a. acid etchant
b. provide for caries-protective fluoride release c. always higher than with a composite resin b. polyacrylic acid conditioner
c. recharge with fluoride d. not clinically relevant c. basic phenol
d. all of the above 11. Glass ionomer cements are not recom- d. none of the above
2. Early silicate cements contained _____. mended as definitive restorations for the 19. _____ require pre-treatment with a
a. fluoroaluminosilicate glass permanent dentition in stress-bearing cavity cleanser.
b. phosphoric acid areas because they do not have _____. a. Conventional glass ionomer cements and zinc-
c. hydrochloric acid a. the wear resistance of amalgam reinforced glass ionomer cements
d. a and b b. the wear resistance of composite resin b. Resin-modified glass ionomer cements and
3. Zinc-oxide and polyacrylic acid are c. the resistance to chemical erosion of amalgam or zinc-reinforced glass ionomer cements
composite resin c. Conventional glass ionomer cements and resin-
contained in _____.
d. all of the above modified glass ionomer cements
a. zinc phosphate cement
d. none of the above
b. zinc oxide cement 12. Contact with water during the initial
c. glass ionomer cement placement and early setting of conven- 20. The mechanism of action for adhesion of
d. zinc polycarboxylate cement tional glass ionomers can cause _____. glass ionomer cements to enamel is _____
4. The first type of glass ionomer cement was a. the setting reaction to be accelerated between the glass ionomer and the _____
developed by _____. b. the setting reaction to be delayed within the tooth structure.
c. the setting reaction to cause extensive shrinkage a. a molecular bond; hydrogen
a. Thatcher and Kent
d. none of the above b. a molecular bond; calcium
b. Thatcher and Bent
c. an ionic bond; calcium
c. Wilson and Bent 13. For powder-liquid RMGI, the propor- d. none of the above
d. Wilson and Kent tion of self-setting acid-base reaction in
RMGI is a _____. 21. When using RMGI to increase the bond
5. Compared to composites, conventional
to enamel, it is recommended that the
glass ionomer cements generally have a. minor part of the setting reaction
enamel be _____.
_____. b. major part of the setting reaction
a. removed
a. relatively poor physico-mechanical properties c. factor in polymerization shrinkage
b. etched
b. relatively poor biological properties d. all of the above
c. beveled
c. less resistance to wear 14. For most resin-modified glass ionomers, d. any of the above
d. a and c it is recommended that the material be
22. The bond to dentin with glass ionomers
6. Resin-modified glass ionomer cement placed in increments no greater than
is _____.
was developed by adding chemistry was _____ deep.
a. unpredictable
enhanced with the addition of _____ to a. 1 mm
b. predictable
the formulation of conventional GIC. b. 2 mm
c. poor
a. water-soluble photopolymerizable resin monomers c. 3 mm
d. a and c
b. 2-hydroxyethylmethacrylate d. 5 mm
c. alkaline phosphatase 23. When shear bond strength to dentin
15. _____ is used to remove the smear has been evaluated it has been noted that
d. a and b
layer prior to placement of glass ionomer when stressed there is a _____.
7. A resin-modified glass ionomer is _____. cements. a. separation of the glass ionomer from the dentin
a. dual-cured a. 35% phosphoric acid etchant b. aggressive fracture of the enamel
b. self-setting b. Acetic acid cleanser/conditioner c. cohesive fracture of the glass ionomer
c. light-cured c. Polyacrylic acid cleanser/conditioner d. a or c
d. all of the above d. all of the above
24. When restoring Class V non-carious
8. Metal-reinforced glass ionomers were 16. Zinc-reinforced glass ionomer is com- cervical lesions with RMGI, it was found
developed by adding _____ to GIC. bined with a novel acrylic acid copolymer that the dentin should be _____.
a. gold alloy powder that improves _____. a. lightly smoothed
b. silver amalgam alloy powder a. wear resistance b. lightly roughened
c. iron oxide particles b. fracture toughness c. prepared with a rotary instrument to create a
d. all of the above c. flexural strength uniform dentin smear layer
9. The setting shrinkage of glass ionomer d. all of the above d. b and c
cement is _____ composite resin. 17. Zinc-reinforced glass ionomer has a 25. Whenever placing Class V restorations,
a. higher than for _____ consistent with good readability in potential contamination with _____ is a
b. the same as for radiographs. risk factor.
c. lower than for a. radiopacity a. moisture
d. none of the above b. radiolucency b. sulcular fluid
10. The fluoride release of a resin-modified c. translucency c. cellular defects
glass ionomer is _____. d. all of the above d. a and b

www.ineedce.com 13
Online Completion
Use this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the
online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your
answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed
and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

Questions

26. Water _____ GIC. 35. For many patients, access with a curing a. 58%
a. plays a critical role in the fluoride release of light to the distal and lingual surfaces b. 68%
b. is part of the acid-base reaction for setting of posterior teeth is not possible due to c. 78%
c. is one of the constituents of _____. d. 88%
d. all of the above a. tooth position
44. Three years after resin sealant place-
27. When resin-modified glass ionomer b. angulation of the curing light tip
c. inadequate lighting ment, it has found that fully erupted,
cement was compared to amalgam for
d. a and b sealed teeth required _______ replace-
Class II restorations in primary molars,
ments.
the RMGI exhibited ____ at the margins. 36. The treatment of deep caries in vital
a. 0%
a. less recurrent caries teeth without pulpal invasion has been
b. the same level of recurrent caries b. 5%
referred to as _____.
c. more recurrent caries c. 10%
a. endodontic control
d. none of the above b. caries control d. 15%
28. Findings suggest that RMGI enhance c. prophylactic filling 45. It has been found that if the gingival
the _____. d. none of the above tissue was over the distal marginal ridge
a. prevention of enamel demineralization on the 37. Reinforced zinc oxide and eugenol was at the time of placement, the replacement
restored teeth for many years the material of choice for rate was _______.
b. prevention of enamel demineralization on adjacent temporary restorations for deep carious a. 34%
teeth lesions because it _____. b. 44%
c. prevention of remineralization a. synthesizes an external stimulus c. 54%
d. a and b b. awakens the pulp d. none of the above
29. _____ can be used to recharge the GIC c. has a sedative effect on the pulp
with fluoride. d. none of the above 46. Glass ionomer pit and fissure sealant
a. Topical fluoride gel applications _____.
38. Reinforced zinc oxide and eugenol a. can be used predictably on newly erupted or
b. Fluoride-containing toothpastes
(ZOE) temporary restorations _____.
c. Fluoride-containing mouth rinses semi-erupted teeth
a. inhibit polymerization
d. all of the above b. allows for fluoride release to the surrounding tooth
b. can have a negative effect on resin adhesion
30. Placement of Class V etch-and-rinse ad- structure
c. do not bond to tooth structure
hesive composite resin restorations_____. d. all of the above c. offers significant benefits when sealing an erupting
a. is preferred posterior tooth
39. Zinc-reinforced glass ionomer does not d. all of the above
b. can be problematic
require _____.
c. is suitable for fluoride release 47. In recent years glass ionomer cements as
a. mixing
d. allows for improved recharging of fluoride
b. pre-treatment with a conditioner direct restorative materials have _____.
31. Gingival recession of 3 mm or more has c. a special coating during the setting reaction a. become more user friendly
been reported to be present in at least d. b and c b. offered improved physical properties
_____ of the adult population in one or c. encompassed several types of reinforced glass
40. A _____ can be used to safely remove
more teeth. ionomers
a. 12%
caries from dentin to avoid the potential
for a mechanical pulpal exposure. d. all of the above
b. 17%
a. caries-invading stainless steel bur 48. Glass ionomer cements are now available
c. 22%
d. none of the above b. sharp explorer that are _____.
c. caries-removing polymer bur
32. In Class V preparations, the use of a. resin-modified
d. none of the above
inverted cone burs is preferred because of b. metal-reinforced
the _____. 41. Primary enamel is less wear resistant c. zinc-reinforced
a. reduced risk of over-preparing the cavity than _____. d. all of the above
b. reduced risk of lacerating the tongue a. permanent enamel
b. amalgam
49. Glass ionomer cements can also play an
c. reduced risk of lacerating the gingiva important role in _____.
d all of the above c. composite
d. all of the above a. restoring hopeless teeth
33. The function of the primer is to _____. b. controlling rampant caries
a. wet the surfaces of the cavity preparation 42. Resin-based sealants are _____ at
c. controlling periodontal disease
b. facilitate adhesion of the restorative material preventing pit and fissure caries on
d. all of the above
c. acid etch the enamel posterior teeth.
d. a and b a. ineffective 50. The release of fluoride and recharge with
34. A flexible cervical matrix is used to _____.
b. moderately effective fluoride is part of the unique chemistry of
c. highly effective a _____.
a. fit the contour of the tooth
d. none of the above a. composite resin
b. minimize excess of restorative materials for easier
finishing 43. A review of sealants found that they b. glass ionomer cement
c. adapt and shape the restoration before light curing reduced dental caries by _____ at c. silicate cement
d. all of the above one year. d. all of the above

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 ANSWER SHEET

Glass Ionomers For Direct-Placement Restorations

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All questions should have only one answer. Grading of this examination is done
manually. Participants will receive confirmation of passing by receipt of a verification
form. Verification forms will be mailed within two weeks after taking an examination.
EDUCATIONAL DISCLAIMER
The opinions of efficacy or perceived value of any products or companies mentioned
in this course and expressed herein are those of the author(s) of the course and do not
necessarily reflect those of PennWell.
Completing a single continuing education course does not provide enough information
to give the participant the feeling that s/he is an expert in the field related to the course
topic. It is a combination of many educational courses and clinical experience that
allows the participant to develop skills and expertise.
COURSE CREDITS/COST
All participants scoring at least 70% on the examination will receive a verification
form verifying 3 CE credits. The formal continuing education program of this sponsor
is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for
current term of acceptance. Participants are urged to contact their state dental boards
for continuing education requirements. PennWell is a California Provider. The California
Provider number is 4527. The cost for courses ranges from $39.00 to $110.00.
Many PennWell self-study courses have been approved by the Dental Assisting National
Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet
DANB’s annual continuing education requirements. To find out if this course or any other
PennWell course has been approved by DANB, please contact DANB’s Recertification
Department at 1-800-FOR-DANB, ext. 445.
RECORD KEEPING
PennWell maintains records of your successful completion of any exam. Please contact our
offices for a copy of your continuing education credits report. This report, which will list
all credits earned to date, will be generated and mailed to you within five business days
of receipt.
CANCELLATION/REFUND POLICY
Any participant who is not 100% satisfied with this course can request a full refund by
contacting PennWell in writing.
© 2011 by the Academy of Dental Therapeutics and Stomatology, a division
of PennWell

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